Peripheral arterial disease

Peripheral arterial disease (PAD) affects about 8 million Americans, or 12% to 20% of people over age 65, according to the American Heart Association. PAD is a strong marker for atherosclerosis and many patients with symptomatic PAD also have coronary artery disease. Severe PAD manifests as rest pain, ulcers and gangrene, and is the leading cause of leg amputation. PAD severely impacts patients' quality of life and significantly increases their risk of cardiovascular mortality.

The diagnosis of PAD is complicated by the fact that many patients are asymptomatic. Only about 10% of people with PAD complain of classic intermittent claudication; but they have a six-fold increased risk of cardiovascular mortality and a three-fold increase in all-cause mortality. Although one-third to one-half of patients report severe symptoms, including muscle pain or cramping from intermittent claudication, many others report no serious symptoms. Screening for the disease allows early diagnosis and treatment to reduce cardiovascular risk factors and improve functional status. It is important to treat patients with mild PAD medically and with risk factor modification as aggressively as those with severe PAD, in order to reduce cardiovascular risks and stave off heart attacks, stroke and kidney failure.

For many, PAD may be the first sign that they have a higher than average risk of death from stroke and heart attack. As a result, it is important to motivate patients diagnosed with PAD to make changes in their lifestyle, including structured exercise, diet and smoking cessation, and to encourage them to take long-term medications that can improve or mitigate symptoms. Surgery is an option for people with severe symptoms in order to improve blood flow through the arteries to treat severe pain or allow healing. Physicians should communicate to their patients that, although serious, PAD is treatable.

This supplement to ACP Observer is designed to guide internists in screening, diagnosing and treating the symptoms of PAD.

Key points on PAD

An ABI below 0.9 or above 1.3 is indicative of PAD.

The ABI correlates with lower extremity function and cardiovascular risk in patients with PAD.

Cardiovascular risk factor reduction, including smoking cessation, statin therapy, an angiotensin-converting-enzyme inhibitor, antiplatelet therapy, and blood pressure and blood sugar control are important components of therapy.

β-blockers are no longer contraindicated in patients with PAD.

A supervised exercise training program should be considered for patients with claudication.

Cilostazol is indicated for the treatment of severe claudication in the absence of heart failure.

Invasive treatment of PAD should be reserved for patients with severe disability pain or tissue loss and with lesions anatomically amenable to intervention.

Patients with all peripheral arterial grafts should be given long-term antiplatelet therapy and statins if tolerated.

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